Provider Demographics
NPI:1154315034
Name:CARSON FOOT CLINIC A PODIATRIST GROUP INC
Entity Type:Organization
Organization Name:CARSON FOOT CLINIC A PODIATRIST GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BUU
Authorized Official - Middle Name:KIM
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:310-518-3972
Mailing Address - Street 1:500 E CARSON ST
Mailing Address - Street 2:STE 112
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-2713
Mailing Address - Country:US
Mailing Address - Phone:310-518-3972
Mailing Address - Fax:310-518-3998
Practice Address - Street 1:500 E CARSON ST
Practice Address - Street 2:STE 112
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745-2713
Practice Address - Country:US
Practice Address - Phone:310-518-3972
Practice Address - Fax:310-518-3998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2351213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E23510Medicaid
WE1025Medicare ID - Type Unspecified
CA000E23510Medicaid
0891380001Medicare NSC